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Paste Manufacturer
overview of conditions where splint
therapy fits into occlusal management.
Doric ES bite Davis Schottlander & Davis Ltd, Letchworth, Herts, SG6 2WD, UK As stated above, in dysfunctional
Futar D Occlusion Kettenbach Dental, Kettenbach, D–35713, Eschenburg, Germany
patients, the use of a splint will
disengage the occlusion and may reduce
Memosil 2 Heraeus Kulzer GmbH & Co. KG, Gruner Weg 11, abnormal muscle activity. Alternative
D-63450 Hanau, Germany
modes of splint action have also been
Regisil PB Dentsply DeTrey GmbH, D-78467, Konstanz, Germany described. The stabilization splint, also
known as the Michigan splint, Tanner
Stat BR Kerr UK Ltd, Peterborough PE3 8SB, UK
appliance or centric relation appliance, is
VPS-Bite Henry Schein Holdings Ltd, Southall, Middx, UB2 4AU, UK deceptively difficult to make and fit.
Its features are:
Table 1. Polysiloxane bite registration pastes.
l Constructed of hard acrylic;
tooth, non-working contact) which occlusal factors and TMJPDS,2,3 the l Full occlusal coverage of either
previously was a physiological response provision of an occlusal stabilization upper or lower arch (generally
(e.g. to an extraction) becomes splint in cases of TMJ dysfunction, upper);
pathological should pain, bone loss or muscle hyperactivity or bruxism has l Removable ideal occlusion (RCP
fractured cusp occur. Generally, in the been recommended BEFORE embarking and ICP co-incident; anterior
absence of any signs or symptoms, on adjustment/equilibration.4 The guidance providing posterior
prophylactic removal of non-ideal rationale for this is that occlusal disclusion);
contacts is not advisable. Clearly, these adjustment is indicated in a patient l Worn at night but, if bruxism/
non-ideal contacts have potential to dependent upon full-time splint therapy clenching occurs during the day,
become interferences which do require for symptom relief, with symptoms daytime wear also.
occlusal adjustment. Recording and returning on splint removal. The
monitoring such contacts are of value. influence of cognitive behavioural Upper and lower alginate impressions
The above does not apply in crown and therapy, the placebo effect, should not are taken with a facebow record and an
bridgework. In this situation, should a be under-estimated as bruxists with RCP record. This is by definition a tooth
prospective bridge abutment have a severe attrition were shown to have apart record but within the retruded arc
potential interference (i.e. has a non- increased trait anxiety levels and thus of closure. The author favours an
ideal contact), then its removal prior to experience greater stress in negative anterior jig made in greenstick
preparation for a retainer will avoid its situations.5 Nonetheless, occlusal impression compound or Duralay which
re-introduction, and prevent future therapy has been shown to have both is positioned over the upper incisors
problems. Hence, the importance of subjective and objective effects on (Figure 1). The mandible is rotated
occlusal analysis before embarking on dysfunction.6 whilst the condyles are in the terminal
advanced restorative dentistry and the hinge axis (see later), so that the lower
need to plan with the aid of a dental incisors indent the soft jig with the
articulator (next paper in the series). It is THE OCCLUSAL posterior teeth about 2 mm apart. When
generally accepted that, if the anterior STABILIZATION SPLINT the jig is hard, a suitable polysiloxane
slide from RCP to ICP is more than 1 mm, AND THE RCP RECORD bite registration paste (see Table 1) is
or has a lateral component, then It is not the purpose of this section to syringed into the interocclusal posterior
adjustment is necessary. This is give a comprehensive review of splint gap bilaterally (Figure 2a and b). When
particularly the case when: therapy but to give the reader an this is set, the jig is removed, and further
Given the irreversible nature of both Figure 2 (a, b). Bite registration paste is syringed into the inter-occlusal space whilst the patient
adjustment and equilibration, plus the bites on the jig in RCP
contentious relationship between
CLINICAL PROCEDURES
Achieving RCP
Figure 6. Bilateral mandibular manipulation
Figure 5. Chin point guidance into RCP. The starting point for an occlusal into RCP. This is easier if patient is sitting upright.
The RCP Premature Contact Figure 9. (a) Initial contact in RCP on second
Figure 8. Prematurity identified and marked premolars, marked with pencil. (b) Horizontal
with indelible pencil. Adjustment made with slow The elimination of an RCP prematurity
and lateral slide greater than 1 mm into ICP.
speed diamond wheel (Horico, W068 045). requires judicious grinding of the upper
Posterior Contacts on
Protrusion
These can be eliminated by either
RLE posterior grinding or increasing the
steepness of the anterior guidance. The Figure 13. Posterior contacts on protrusion.
lower incisors are to all intents and DUML applies. Distal facing inclines of Upper
teeth or Mesial facing inclines of the Lower teeth
purposes akin to supporting cusps and are ground. Increasing the steepness and length
are thus not to be ground down. The of the incisal guidance has a similar effect.
palatal inclines of the incisors are
equivalent to guiding cusps/inclines
and can be adjusted by grinding and conform to the existing maxillo-
RLE hence reducing anterior guidance or by mandibular relationships such as ICP.
the addition of acrylic on provisional As mentioned previously, minimal local
Figure 11. Right working side interference. adjustment is acceptable. Removal of a
restorations and so increasing anterior
Removal of upper buccal incline or lower
lingual incline depends on maintenance of guidance. Removal of posterior contacts plunger cusp and non-working contacts
supporting cusp vertical dimension. Hence on protrusion follows the DUML rule, on teeth intended for preparation fall
BULL rule. distal facing contacts on upper teeth or into this category. A prematurity on
mesial facing contacts on lower teeth closure into RCP can be adjusted as
(Figure 13). mandibular repositioning during
overerupted teeth than in fully preparation is undesirable.
dentate, well aligned arches where
canine guidance or partial group THE CONFORMATIVE
function is to be expected. For APPROACH The Reorganized Approach
working side interferences apply the As its name suggests, restorations The entire occlusal scheme is modified,
BULL rule. Buccal Upper and Lingual
Lower cusps are non-supporting
cusps, whereas Palatal Upper and a b
Lower Buccal cusps (in a normal
Class I bucco-lingual relationship)
support the Occlusal Vertical
Dimension (Figure 10) and should
not be adjusted. Interferences on
buccal upper or lower lingual cusps
are ground to provide working side
canine rise or smoother guidance
Figure 14. (a, b) Painted upper cast before and after identification of initial contact in RCP on
with several teeth in contact (Figure the upper left first molar mesio-palatal cusp.
11).
which may include co-incidence of RCP thickness will result in the initial A Textbook of Occlusion. Chicago: Quintessence
Publ. Co., 1988.
and ICP as the former becomes the contact being identified, marked and
5. Monteiro da Silva AM, Oakley DA, Hemmings
starting point for all mandibular adjusted. The dentist notes where this KW, Newman HN, Watkins S. Psychological
movement. Planning and reproducing initial contact occurred and then factors and tooth wear with a significant
such extensive occlusal re-organization assesses the new occlusal relationship. component of attrition. Eur J Prosthodont Rest
Dent 1997; 5: 51–55.
in crown and bridgework requires a 6. Wassell RW. Do occlusal factors play a part in
semi-adjustable articulator. This will be temporomandibular dysfunction? J Dent 1989;
discussed in the next paper in the 17: 101–110.
series. R EFERENCES 7. Lauritzen AG, Wolford LW. Occlusal
1. Beyron H. Optimal occlusion. Dent Clin N Am relationships: The split-cast method for
Most dental treatment is 1969; 13: 537–554. articulator techniques. J Prosthet Dent 1964; 14:
conformative in nature. Dentists 2. Forssell H, Kalso E, Koskela P, Vehmanen R, 256–265.
unfamiliar with the steps involved with Puukka P, Alanen P. Occlusal treatments in 8. Dawson PE. Evaluation, Diagnosis and Treatment
temporomandibular disorders: a qualitative of Occlusal Problems, 2nd ed. St Louis: CV Mosby,
occlusal analysis and adjustment would systematic review of randomised controlled 1989.
be well advised to practice adjustment trials. Pain 1999; 83: 549–561. 9. Yuodelis RA, Mann WV. The prevalence and
on study casts articulated in RCP, 3. Ekberg E,Vallon D, Nilner M. Occlusal appliance possible role of non working contacts in
having painted the occlusal surfaces therapy in patients with temporomandibular periodontal disease. Periodontics 1965; 3: 219–
disorders. A double blind controlled study in a 223.
with a suitably coloured poster paint short term perspective. Acta Odontol Scand 1998; 10. Shillingburg HT, Hobo S,Whitsett LD.
(Figure 14a and b). Removal of the RCP 56: 122–128. Fundamentals of Fixed Prosthodontics. Chicago:
record and closure through its 4. Mohl ND, Zarb GA, Carlsson GE, Rugh JD. Quintessence Publ. Co., 1981.